The Australian Transport Safety Bureau (ATSB) is Australia's national transport safety investigator. The ATSB's function is to improve safety and public confidence in the aviation, marine and rail modes of transport. The ATSB is Australia's prime agency for the independent investigation of civil aviation, rail and maritime accidents, incidents and safety deficiencies.

Summary

Summary

The pilot of a Cessna 182J was conducting a private visual
flight rules (VFR) flight, with one passenger, from Lightning Ridge
to Caloundra. The passenger was also a qualified private pilot.

Prior to departure at about 0845 EST, the pilot obtained an
Airservices Australia location briefing containing weather and
notice to airmen (NOTAM) information relevant to the flight. At
about 1000, the pilot used a mobile phone to contact an associate
in Lightning Ridge. The pilot indicated that he was over
Goondiwindi, tracking via Toowoomba for Caloundra, and that the
weather was not good.

At approximately 1100, the Australian Defence Force (ADF)
Amberley approach controller observed an unidentified code 1200
secondary surveillance radar (SSR) return in close proximity to the
boundary of military airspace, about 10-12 NM north-east of
Toowoomba. Code 1200 is allocated to VFR flights operating outside
controlled airspace and not participating in a radar information
service. The SSR return provided unverified mode "C" altitude
information that indicated the aircraft was at 5,700 ft above mean
sea level. The controller soon became concerned that the aircraft
was going to enter controlled airspace, and that it might conflict
with a General Dynamics F111 that was inbound to Amberley from the
north with an in-flight emergency.

The controller attempted to contact the pilot of the
unidentified aircraft by making a number of general broadcasts on
the Amberley approach frequency. The controller also requested that
the Airservices Australia Downs radar advisory service controller
make a general broadcast for the pilot to contact Amberley
approach, which he did at 1106:37. The Amberley approach controller
informed the pilot at 1107:57 that his aircraft was identified on
radar. At that time the aircraft was inside Amberley controlled
airspace bearing 310 degrees M and 30 NM from Amberley. The pilot
was immediately instructed to conduct a left orbit to provide
separation with the F111.

During the orbit, the pilot advised the controller that the
aircraft was "caught in cloud" and that he was "in trouble". A
number of broadcasts between the controller and the pilot
subsequently took place as the controller attempted to clarify the
situation. During that time, the pilot asked whether he could use
the automatic pilot. The quality of the radio transmissions from
the aircraft was poor and the controller had difficulty in
comprehending the full extent of the problem and the pilot's
request to use the autopilot. The controller reported that these
difficulties were exacerbated by the pilot's accent.

By the time the controller established that the pilot wanted to
track to Caloundra and was rated only for VFR flight, but was in
instrument meteorological conditions (IMC), the pilot had commenced
a second left orbit. The aircraft was approximately half-way
through the second orbit, passing a heading of approximately 240
degrees when the controller instructed the pilot to turn right and
take up a northerly heading for Caloundra. While the aircraft was
in the right turn, the controller asked the pilot if he wanted
descent, to which the pilot replied in the affirmative. The
controller then cleared the pilot to leave control area on
descent.

Changes in the aircraft's altitude during the right turn were
erratic. Radar recordings indicate that the aircraft descended to
4,400 ft in less than a minute, then climbed back to 4,800 ft. The
pilot maintained the right turn onto a heading of about 130 degrees
before making a left turn to intercept the track from Toowoomba to
Caloundra. During that time, the controller advised the pilot that
he could descend to 3,000 ft safely in the aircraft's current
location. Once established on track to Caloundra, the aircraft
maintained a steady heading, with a rate of descent of about 300
ft/min.

After the aircraft was established on track for Caloundra and
was still in IMC, the controller became concerned that the aircraft
was heading for an area of higher terrain, where the radar lowest
safe altitude, as specified on the radar terrain clearance chart,
was 3,800 ft. As a result, the controller instructed the pilot to
turn right heading 130 degrees (a turn of about 90 degrees). The
aircraft was passing 3,700 ft when the pilot commenced the right
turn. Recorded radar data indicated that the aircraft continued the
right turn through the assigned heading and that the aircraft
ground speed and rate of descent increased during the turn.

The aircraft SSR return disappeared from the radar display at
approximately 1116 as the aircraft was passing 3,200 ft on a
heading of about 210 degrees. Controllers at Amberley reported that
that was consistent with known radar coverage in the area. The
pilot responded to a question from the controller regarding the
aircraft's in-flight conditions at approximately 1116:00. Radio
contact with the pilot was lost after that time. The Amberley
approach supervisor subsequently contacted the emergency services
number to find out if there had been any reports of accidents. The
supervisor was switched through to Ipswich police, who advised that
they had received a report of an accident in the Esk area.

The wreckage of the aircraft was located approximately 6.5 km
north of Esk on flat pastoral land. A nearby resident caught a
glimpse of the aircraft just before impact and then observed a
plume of fuel and debris. He immediately notified emergency
services, who recorded the call at 1117:30. Impact evidence
indicated that the aircraft was in a left turn in a nose-low
attitude and that the aircraft was not in a stalled condition. This
is consistent with witness reports that indicate the aircraft was
descending in a left turn. The impact destroyed the aircraft and
both occupants were fatally injured.

Pilot in command

The pilot held a private licence, together with a valid class
two medical certificate, and was appropriately endorsed. However,
he did not hold a rating for flight in IMC, nor was the aircraft
approved for flight in IMC. The pilot had logged a total flight
time of 220 hours, comprising 90 hours dual and 130 hours as pilot
in command by day. No evidence was found that the pilot was
suffering from any medical condition that could have contributed to
the accident.

The pilot was reported as being cautious and conscientious in
his approach to flight preparation and in-flight procedures. In
particular, flying instructors who had flown with the pilot
reported that he was wary of flying in poor weather. The pilot's
logbook indicated that on at least three previous unrelated
occasions, the pilot had abandoned flights and returned to
Lightning Ridge due to adverse weather. An associate of the pilot
reported that he spoke to him prior to his departure on the day of
the accident and that the pilot had expressed reservations about
making the flight to Caloundra. He had stated that he intended
assessing the weather at Goondiwindi before proceeding further.

Aircraft information

A periodic maintenance inspection was due approximately 10 hours
after the commencement of the accident flight and there were no
known outstanding maintenance defects. Evidence indicated that the
engine was operating at impact and examination of the wreckage did
not reveal any deficiencies that were likely to have contributed to
the accident. The aircraft was fitted with an emergency locator
transmitter (ELT), which was destroyed on impact. A global
positioning system (GPS) unit was fitted to the aircraft and the
pilot was also carrying a hand-held unit.

Meteorological information

On the morning of the flight, the pilot obtained area forecasts
(ARFORs) 22, 40 and 41, which covered his route. He also received
terminal area forecasts (TAFs) for relevant en-route airfields and
for Maroochydore and Archerfield, but there was no evidence that he
received a TAF for Caloundra. ARFOR 40 covers a large part of
south-east Queensland, including the eastern Darling Downs and the
Amberley area.

The Area 40 forecast was valid from 0717 to 2100 EST. The
forecast overview indicated cloudy conditions with rain areas and
isolated thunderstorms, clearing from the west after 1800. Forecast
cloud consisted of isolated cumulo-nimbus with a base of 6,000 ft
and scattered stratus between 1,200 ft and 6,000 ft in rain, broken
near thunderstorms. Also forecast was scattered cumulus and
strato-cumulus with a base of 3,000 ft between the coast and the
ranges and 4,500 ft inland, with broken alto-cumulus and
alto-stratus layers above 16,000 ft. The predicted visibility was
5,000 m in rain and smoke and 2,000 m in the vicinity of
thunderstorms.

The TAFs for Archerfield and Maroochydore were current from 0600
to 1800 EST. They predicted visibility in excess of 10 km, light
rain and scattered cloud at 2,500 ft, and also forecast
intermittent periods of reduced visibility down to 4,000 m, rain
and broken cloud at 1,000 ft.

The pilot of the F111 reported that the area was dominated by
large cumulus cloud with associated stratus. He reported that there
were occasional gaps between the cumulus and stratus cloud levels,
which resulted in small pockets of airspace where visual flight was
possible. However, these pockets were only present above 5,000ft
and were totally surrounded by cumulus and stratus cloud. The crew
of the F111 reported that the cloud during their approach to
Amberley, approximately 30 NM to the south-east of the accident
site, was consistent broken low cumulus and stratus with a base of
650 ft above mean sea level.

A Bureau of Meteorology observer at Amberley stated that on the
day of the accident, the weather was influenced by an easterly
moving trough lying north-south through central Queensland and a
north-easterly breeze off the ocean. The observer stated that these
two influences were known to produce a build-up of low cloud
against the ranges. Witnesses on the ground in the vicinity of the
accident site described the weather as showery, with cloud covering
the tops of the hills.

Air traffic services inflight emergency response

Air traffic services (ATS) emergency procedures were outlined in
chapter 17 of the Manual of Air Traffic Services, a joint
military/civil document. Section 3 of chapter 17 provided guidance
on emergency phase declaration. Paragraph 1 stated that "[t]he
appropriate emergency phase shall be declared to show the degree of
apprehension felt for the safety of an aircraft and an indication
of the scope of the SAR [search and rescue] action to be provided."
Paragraph 6 stated that "[a]n Alert Phase exists when there is
apprehension as to the safety of an aircraft and its occupants",
and specifically noted that an Alert Phase existed when a flight
restricted to visual meteorological conditions (VMC) was operating
in IMC.

"While it is impracticable to set out a detailed
response to every emergency situation, it is possible to identify
broad groups of incident types and to generalise appropriate
courses of action".

Paragraph 2 stated:

"In resolving inflight emergencies, units should use
the Inflight Emergency Response Checklists as a basis for the
provision of assistance to pilots".

Information and guidance specific to "Flight confined to VMC but
operating in IMC" was contained in paragraphs 48 to 53 of section
4. Paragraph 48 highlighted the fact that "[t]his type of inflight
emergency is potentially a very serious situation which has often
led to fatal consequences".

The section also provided general guidance to ATS staff on
issues about which they needed to be aware, and strategies to be
employed in responding to this type of in-flight emergency. In
particular, it stated that ATS staff should be aware that a pilot
in this situation would have difficulty with the following:

maintaining headings;

maintaining altitude; and

perceiving aircraft attitude.

Furthermore, the section stated that ATS should endeavour to
provide reassurance to the pilot in the initial communications and
limit communication so as not to divert the pilot's attention from
flying the aircraft.

The ATS strategy for an aircraft in a "VFR in IMC" situation was
detailed in the IFER training manual and stated that it "should
reflect the absolute pilot priority to control the aircraft ahead
of navigation or communications". The following advice to assist
pilots in such a situation was provided in the training manual:

"

Provide the pilot with some reminders on aircraft handling.
While [the controller] is not expected to "fly" the aircraft for
the pilot, the following handling actions are universally
recognised as appropriate basic advice to an inexperienced pilot in
distress:

Provide navigation information to the pilot that will allow the
aircraft to be re-established in VMC.

Communicate with the pilot using the following techniques:

keep instructions simple and distractions to a minimum;

keep regular radio contact without overloading;

instil confidence and reassure the pilot; and

pass only one item at a time

".

The IFER training manual also provided guidance on the
communications style which should be adopted by controllers when
dealing with this type of emergency. Specifically, the manual noted
that a VFR pilot in an IMC situation is under considerable stress
and there was a need for ATS staff to convey empathy, patience and
confidence. This required ATS staff to adopt a markedly different
technique to the customary delivery of ATS information, where
precision and economy of words are appropriate to communications
between confident professionals. Furthermore, in establishing the
necessary background information, it was vital that questions not
be put in an interrogative manner.

The IFER checklists, a document separate from the IFER training
manual, contained items that should be considered when responding
to specific situations. However, checklists serve primarily as an
aide-memoire. A high level of background knowledge and situational
awareness by the controller is required to expeditiously provide
assistance to the pilot. In this regard, while the checklists are a
useful tool, they need to be considered in conjunction with more
detailed guidance, such as that contained in the IFER training
manual.

A review of the audio voice recording revealed that the
controller's manner while communicating with the pilot was
authoritative, with questions being posed in an interrogative
style. The controller used the IFER checklist during communications
with the pilot. However, the unit was unaware of the existence of
the IFER training manual.

The register of copy holders in the front of the IFER training
manual indicated that ADF was a registered holder of three copies.
However, the ADF was unable to locate these copies and the manual
was not held by any ADF ATS unit. Airservices Australia records did
not provide any receipt confirmation advice relating to the
document copy numbers listed against the ADF.